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NALGONDA, Medak & Nizamabad (Andhra Pradesh): Janreddy sat wracked in pain, a picture of ill
health. "Why isn't this man on his way to hospital?" we asked the neighbours crowding around
his bed. "Well," they said nervously, "we just brought him home from one. He was there for
days. This family has already lost all its money on hospitals."

Janreddy died hours after we met him. His daughter-in-law, who became a bonded labourer to keep
the family afloat, will remain one till debts of Rs.5 lakh are paid off. Over Rs.3 lakh of
that was incurred on medical costs. His wife, who donated one kidney to her son - both of his
had collapsed - does any work she can find. The son, Narsi Reddy, confined to home, has to
drink only the purest water in a place where there is none. His medicines cost around a
thousand rupees each month.

The huge medical bills of this family of six were incurred despite the son getting free
operations at the Osmania Government Hospital in Hyderabad. They had first gone to private
hospitals for checkups, a biopsy and other tasks. As the costs mounted they sold off land and
cattle to meet them. That Narsi Reddy had sunk four borewells didn't help. All of them failed.
The crisis on their four-acre farm in Chelliagudam village of Nalgonda district saw Janreddy's
health too, cave in. "They might just have survived the crop failure," say the neighbours, "but
their medical costs destroyed them."

Health spending is amongst the fastest growing components of rural family debt. More so in
Andhra Pradesh. For years, the state boosted the private sector in health, promoted corporate
hospitals and pioneered the "user fees" system in Government ones.

"The Naidu Government dismantled the public health system," says M. Geyanand, a leading doctor
from Anantapur district. Dr. Geyanand is also State president of the Jana Vignyana Vedika
(JVV), a body that aims to promote popular science and the scientific temper. "Ninety per cent
of patients who go to public hospitals are poor. When that system fails them, they turn to
private ones at a huge price. Health costs often count for as much as 20 to 25 per cent in the
total expenditures of such households. And a single medical emergency can ruin them."

A common thread running through the farmers' suicides plaguing the State has been very high
medical spending. Just five households affected by such deaths had health costs totalling
around Rs.4 lakhs. All of them farming families who held between half an acre and three acres
of land. (Some of that mortgaged.) Janreddy's family has not seen a suicide. But it fits this
profile rather well.

As do countless other poor households. Even last year, we ran into a farmer who had attempted
suicide in the Nallamada mandal of Anantapur district. His friends just managed to get him to a
hospital in time. The rescued farmer abused his saviours. The reason: the four-day stay and
treatment in hospital cost Rs.45,000. "I tried to commit suicide because I could not pay debts
of Rs.1.5 lakh," he said bitterly. "Now I owe even more."

Many of those who succeeded in taking their lives this year had huge medical bills. P.
Hanumantha Reddy's family in Nizamabad district owes Rs.2 lakhs. The survivors of A.
Narasimhalu in Medak have to rustle up Rs.70,000 plus interest. The tab for K. Shivarajaiah's
family in the same district is Rs.50,000. All this was money borrowed at absurd rates of
interest.

"There is a link between the suicides and the crisis of health in Andhra," says Dr. Geyanand.
"The collapse of the public health system is crucial. In any poor villages, you can see people
dying of diseases that should not kill them. Malaria is just one example. For years now, all
their support systems have been slashed. The costs are so high, they run out of money halfway
through treatment. Those who fall ill are selling land, gold, cattle and other assets to pay
medical bills. They also take loans they can never repay."

In the past decade, the little access the poor had to health sharply declined. So Gunala Kumar
discovered when he had to fork out Rs.40,000 in medical costs to private hospitals in Medak.
That remains a big chunk in his total debt of over Rs.2 lakhs. A debt that caused him to take
his own life in Meerdoddi village this month. Like his father who committed suicide last year.

"Maybe it is better to die," says Yekalapu Husein of Shabuddlapur in Nalgonda. "How will we pay
the fees they ask us to at these hospitals?" A toddy tapper who suffered a fall from high in a
tree while at work, Mr. Husein has run up huge bills himself. Then came his malnourished wife's
illness. His `medical debt' now stands at Rs.2 lakhs. "Even if we get free care at Osmania
Hospital," he laughs, "we do not have money for the bus fare to Hyderabad and back."

In G. Edavalli village in the same district, the local Rural Medical Practitioner sold all his
land to pay his own treatment costs of Rs.4 lakhs at a corporate hospital in Hyderabad.

In the years these dramas unfolded, public hospitals were starved of funds, medicines and
drugs. Given Rs.600 crores by the World Bank for public health, the Naidu government spent this
mostly on buildings. Very few doctors or nurses were recruited with it. The buildings now show
decay for lack of maintenance. Mr. Naidu also authored a Government `tie-up' with corporate
bodies. Under this, employees of the State went to corporate, not public hospitals. The
Government reimbursed their costs. This meant a windfall for those hospitals. It also meant
many scams in the shape of inflated reimbursement bills. Meanwhile, health institutions in the
public sphere suffered.

"The introduction of `user fees' made health even less accessible to the poor," says a senior
IAS officer. The fees have since been withdrawn by the new Government. Also dumped was an idea
of handing over some super speciality departments of public hospitals to `private management.'
That is, to corporate hospitals.

The damage, though, has been done. The medical costs of those who preferred death to debt still
plague the living. We pass Janreddy's wife at the bus stand, looking for any `coolie work' she
can find. There are, after all, bills to be paid.
(Courtesy: The Hindu)

P Sainath

01 Jul 2004

P Sainath is one of the two recipients of the A.H. Boerma Award, 2001, granted for his contributions in changing the nature of the development debate on food, hunger and rural development in the Indian media.
He is the Rural Affairs Editor at The Hindu.